Treatment



Approximately 80 per cent of patients present­ing with gastrointestinal hemorrhage will stop bleeding spontaneously. In such cases, manage­ment is directed toward prevention of further bleeding by either medical or surgical treatment. Thus, following bleeding from a duodenal ulcer, treatment with antacids, sucralfate, or an H2-re-ception blocker is often initiated. Conservative management is usually undertaken in cases of gas­tritis, Mallory-Weiss tears, angiodysplasia, or div-erticulosis in which bleeding ceases sponta­neously. On the other hand, malignant lesions and polyps are resected either surgically or endoscopically when possible. If bleeding does not cease or recurs, further management will depend upon the site and nature of the lesion as well as upon the assessed ability of the patient to withstand surgery. For example, most cases of peptic ulcer that fail to cease bleeding will require urgent sur­gery.

Several nonsurgical techniques for arresting gastrointestinal hemorrhage have been widely used, although their role is far from clear. These include radiological procedures such as intra-ar-terial infusion of vasopressin, a powerful vaso­constrictor, and selective embolization of bleed­ing arterial foci. Endoscopic electrocoagulation and laser photocoagulation are also becoming in­creasingly used, particularly for elderly, poor-risk patients with angiodysplastic lesions.

Variceal hemorrhage requires special consid­eration. Most patients with variceal bleeding are poor operative candidates and run a high risk of rebleeding. Additional precautions and suppor­tive measures are required in these patients, as bleeding may precipitate hepatic encephalopathy while renal function may deteriorate rapidly . Cleansing of blood from the bowel using enemas as well as administration of lactu­lose helps to lessen the risk of encephalopathy. Volume should be replaced using blood or blood products, with care taken to avoid overtransfu-sion, which can worsen variceal bleeding. Since these patients often retain sodium and water av­idly, infusion of large volumes of saline shouldbe avoided as far as possible, as this will invari­ably aggravate ascites. Initial measures to arrest hemorrhage nonoperatively include intravenous infusion of vasopressin (which is as effective as, but safer than, infra-arterial administration) and clotting factor replacement, usually in the form of fresh frozen plasma and platelets. Balloon tam­ponade is resorted to when bleeding fails to cease, but it is often only a temporary measure. Cur­rently, continued bleeding is usually treated by endoscopic injection of the varices with sclero­sant solutions (sclerotherapy), which is success­ful in arresting bleeding in up to 90 per cent of cases. Emergency decompression of the portal system by means of portosystemic shunt surgery is, at times, the only means for arresting acute var­iceal hemorrhage. Prevention of recurrent bleed­ing from varices may be achieved through either repeated endoscopic sclerotherapy or elective portosystemic shunt surgery.